Though I didn’t set out to become an expert in ADHD, by default, I have ended up working with ADHD fairly often in my practice. This is because ADHD causes relationship challenges when it is unmanaged or when the partner of someone with ADHD doesn’t understand it. In the end, it is fairly simple, and as you probably know, very difficult nevertheless. I’m a licensed psychologist in California, with a Ph.D. in clinical psychology, and these are the six practical elements I use to help my clients manage their ADHD: Sleep, Diet, Exercise, Medications, Therapy, and Mindfulness.

I usually say most people need a minimum of three of these well-dialed in to manage their ADHD, but honestly, my experience says that it is just an upward benefit slope. The more of these you use, the better managed your ADHD will be. Let’s review each one.

How Does Diet Help Manage ADHD Symptoms?

Section TL/DR: Your brain needs the right food to ADHD less, but only the right amounts. I can help you manage this.

Eating well can maximize your cognitive capacity. What does that have to do specifically with ADHD? Well, for one thing, being low on blood sugar can be bad for your ADHD symptoms (even though I know you can kind of thrive in a hyper-focus black hole without eating for many hours). This is because your dorsolateral prefrontal cortex (the brain area that directs attention) thrives on glucose, so if your blood sugar is low, you’ll have difficulty directing your attention where it needs to go or keeping it where it needs to be.

That may not be a problem as long as you’re hyper-focused on the right thing, but heaven help you once you realize how hungry you are and then realize the snack you bought two weeks ago is in the back of the cupboard, and aren’t those the beans you were going to use to make chili . . . oooh, chili! . . .

But the other challenge of ADHD and diet is that if you are too high on sugars, or too many simple carbohydrates, it’ll be hard to focus too. The sugar may make you feel restless, making it hard to keep still. The carbohydrates may be dulling, making it harder to motivate. So, what to do?

Core recommendations to manage eating for ADHD:

• Hide the goodies: Put snacks and sweets hidden away, or better yet, don’t have them in the house in the first place.
• Make fruits and veggies easily accessible, already washed or prepared. This means apples in a bowl right out on the counter, and washed and cut veggies in the eye-level shelf in the fridge. Nuts at hand on the desk for ongoing snacks
• Pre-prepared meals, and for some clients, smaller meals, eaten more often, are better.

How Does Therapy Help Manage ADHD Sleep Issues?

Section TL/DR: You probably need more sleep, but have trouble getting it. I can help with tailored interventions.

Sleep is a cornerstone for mental health of all kinds. Anyone who wants to maximize their wellness and minimize the impact of their mental health should be paying attention to quality sleep as a cornerstone, but when it comes to managing sleep for ADHD specifically, there are some key elements to consider.

Sleep Onset Problems

Subsection TL/DR: ADHD Sleep Onset Problems are usually structure problems or impulse control problems. I can help with both.

Stayed awake till 2a again because you were completing that project before the 8a deadline? Or were you telling yourself you should go to bed, but just couldn’t make yourself stop what you were doing long enough to do so? ADHD related sleep onset problems are usually either structure problems like staying up to finish a deadline or, impulse and attention regulation problems like getting stuck on your phone.

Therapy helps manage ADHD sleep-onset problems by assessing the type of problem and gives you concrete and ongoing support for addressing your specific sleep-onset challenges. For example:

• Using time in the session for you to create small accountability deadlines. For example, getting you to email your colleague, “Can I show you how the big project is coming along and get your input tomorrow?” or to email your boss, “Hey, can we schedule a meeting 3 days before the big deadline so I can show you my draft?” This helps you use therapy to create real-world accountability, so you make incremental progress before the real deadline.
• Sucked in by an app? We’ll identify in session ways to limit the app from deleting it, to limiting it in your phone’s settings, to creating alarms that will interrupt you (yes, more than one). Up late playing video games? We won’t just talk about how you need to stop; we’ll find ways to time box your fun time, set timers when you begin, or put the power cord on a vacation timer.

Notice how I emphasize action in session as much as possible? We have to catch this moment of attention and make sure it is making a difference for you when you aren’t thinking about the session. More about that in a minute.

Early Waking Problems

Subsection TL/DR: Early waking is the most common ADHD related sleep problem I see in my practice. By hearing what you experience when you wake, we’ll strategize tailored solutions for you.

The ADHD challenge with sleep is usually early waking. Most of us have a sleep cycle of around 90 minutes. Between those cycles, we are in the lightest sleep, and we change positions. When a person has ADHD, after about 6 hours of sleep (4 sleep cycles), people with ADHD often wake up too much. Their minds start to hear birds chirping, or they start thinking about what they need to do during the day. Then they can’t shut their mind off, they wake up early. And usually feel fine, but . . .

Most people need 8 hours of sleep (a 5^th sleep cycle +/- a little time between cycles) in order to be fully balanced. The person with ADHD may not even feel the effect of only getting 6 hours of sleep, but if they ever got another sleep cycle, they would likely feel the benefits.

So, therapy for managing ADHD helps the client stay asleep by:

• Checking in regularly with you about your sleep cycles so you don’t forget how important it is.
• Reviewing sleep disruptions like early waking and troubleshooting actionable solutions. For example, being a little warmer can often help people stay in deeper sleep. Or guiding you to keep the room darker so the light doesn’t wake you up as much.

Once we have some things for you to try, I’ll ask you to set an alarm for after the session to help you remember to implement the suggestion. That’s because I’m not going to just come up with ideas; I’m going to help you implement them, recognizing that your ADHD is a barrier.

Good job reading that whole thing. That was a long one, but the next one is shorter, so you can do it!

How Does Therapy Help Manage ADHD Exercise Challenges?

Section TL/DR: Brain does better when you get out your zoomies. I help you exercise without getting rigid about how.

There’s a strong connection between cardiovascular health and cognitive functioning. For people with ADHD, you can also get physical restlessness, zoomies, out by exercising. Here are my top recommendations:

• Minimum of 30 minutes of exercise, any time, any type. <=That’s good and much better than nothing.
• Mid-range: Complete exercise 3 or more hours before bed so the exercise isn’t keeping you awake, and emphasize getting your heart rate up.
• Ideal: As much exercise as you can reasonably fit in, with a combination of strength-based exercise and cardio in the morning before you do anything else.

Notice how I emphasize a range of possibilities without getting rigid about what it has to look like to count?

How Does Therapy Help Manage ADHD Attention Problems?

Section TL/DR: Some people with ADHD swear by meditation. If that’s you, I’ll keep you on it. Otherwise, I don’t torture people with forced meditation.

Some research evidence suggests that mindfulness training is good for people with ADHD[1]. Other research meta-analyses are less conclusive[2], but still suggest some reductions in ADHD symptoms from mindfulness-based intervention. What’s clear to me is that most of my clients with ADHD find mindfulness excruciating. If it is already working for you, or you want to try it, we can incorporate it into your treatment plan. Otherwise, I don’t usually force it.

When I do include mindfulness-based interventions for ADHD, I usually teach a little bit in session and then outsource daily mindfulness practice to an app.

Good job, getting through that section!

How Does Therapy Support Medication to Manage ADHD?

Section TL/DR: Medication can help a lot of people and can be one important support, but I don’t push.

Whether you’re taking a stimulant, Strattera, or a psychiatric medication for another diagnosis, medication management of symptoms is an important aspect of ADHD management. I liken this to weight lifting. Sure, it is great if you can lift a heavy weight a few days a week. But since you have to lift this weight every day for the rest of your life, wouldn’t you like something to lighten the load?

There’s often a little grieving that goes into accepting medication support. A lot of people with ADHD grew up being told they should be able to do this. Especially highly-intelligent and high-performing people, as I see in Silicon Valley, often feel like, “I can do X, Y, and Z, I should be able to manage my ADHD without medications.”

But the thing is, ADHD is an invisible disability. I know you anticipate this big experience of relief and reward once you finally do “it” right. The irony is that for some of my most medication-resistant clients, medication is the support that finally lets them achieve their goals.

How Does Therapy Help Manage ADHD Structure Challenges?

Section TL/DR: You need help to manage the big stuff and the small stuff, and I have a lot of tools for that. I know this feels impossible. Read the section. You’ll see that I’ve got you.

Macro Structure

A core element of ADHD treatment is called externalizing the function. It means you take the part you have a hard time managing by just remembering, and you let something else in your life handle it for you. That’s structure. There are 3 main macro structures that I use with my clients, and I’m supportive of whichever one(s) work for you:

• To-do lists
• Calendars
• Routines

The thing is, we don’t expect them to work forever. There’s a trick to making this work. We let them fall apart, and then I use the last tool mentioned below in the How Does Talk Therapy Help Manage ADHD for Me? section. Aren’t you just dying to see what that is? Go ahead and scroll down to Constant Construction and Destruction. I’ll make sure you don’t miss anything.

Micro Structure

Those help take care of the macro parts of your life. Then there are smaller structures that can help you manage smaller moments like:

• Alarms – Yes, like setting alarms on your phone. But we’ll often do something I’ve never heard someone else suggest. I’ll help you regularly review the alarms in your phone and change the alarm ring tone (“Oh, what’s that noise! That’s something new” <= That makes it harder to just ignore), and we change the time by just a few minutes. This also helps break your attentional blindness so you notice and act on what the alarm was supposed to help you do.
• Tethers – Like literally seatbelting yourself to your chair at work. This can help you stay on task until completion. You say, “But sometimes I need to go to the bathroom? What do I do then?” Keep reading.
• Reminders – So you have to get up from your desk, but you really need to come back. How will I remember to come back? Maybe you tie a piece of string from the desk to a belt loop, or leave your glasses at the desk (But Eric, “I’m almost blind without my glasses.” Exactly)
• Behavioral Interrupts – This is like putting the shoes you’re going to wear immediately in front of the door and putting your keys in the shoes, and putting a post-it on the mirror saying your keys are in your shoes, and your shoes are in front of the door. These are ways of making sure that you can’t get to point B (out the door with your shoes on) without going through point A (getting your keys)
• Rewards – When you complete hard work doing things you don’t want to do, giving your brain a little reward helps a lot. I commonly recommend the following:
  • Sugar: Like one spoonful of ice cream.
  • Salt: Like a small bag of chips
  • Fat: Like ice cream or chips
  • Sex: Not literally in most cases. I mean a positive sensual experience, like a warm bath, rubbing your head, or listening to your favorite song.
  • Cash: Literally moving some cash from a “bank” to a “[Specific Anticipated] Reward” jar.
  • Video Games: Hey, it is fun to experience competence at discrete and achievable goals, and life gives us too damn few of those. Sometimes, we need to live it up.

The key to making rewards work is that they have to be experienced only when you get them as a reward. I know what you’re thinking, “So I only get to have ice cream as a reward?” No, but maybe only your favorite ice cream. It’s a negotiation; we’d talk and make it work for you.

How Does Talk Therapy Help Manage ADHD?

Section TL/DR: Only someone who understands how to treat ADHD knows how to write this much about it and then knows you are going to read the TL/DRs anyway. I’m cool about that and non-shaming.

If you scan back to the writing above, you’ll see many of the core elements of talk therapy for managing ADHD. The key elements are:

• Celebrate successes. ADHD loves a good cheerleader.
• Identifying the way ADHD causes problems for you.
• Trying to set management goals that could work for you.
• Then, because I understand how ADHD interferes with your ability to put that into action, we use time in the session to create the scaffolding so that your intention to make a change in the office goes with you out into the real world.
• Expect you to have ADHD, but don’t have it myself. One of the things that I love about working with people with ADHD is watching threads drop off their attention and me picking their attention up (without shame) and bringing them back.

Eventually, we get to a routine in the sessions. We’ve identified which of these management strategies you’re going to use, and we know how.

We review your core ADHD management strategies every session

For example, I might check in with a client every week on the same 5 things: Sleep, exercise, meds, structure, and that project at work. This means we don’t let ADHD distract you from constantly trying to manage these elements of your life.

Accepting Constant Construction and Destruction

Every other system for managing your ADHD, like Pomodoro, that ADHD workbook, the organizer, or that coach, has only told you a half-truth. The half-truth part is that they are great for managing ADHD. The false part is that they imply their system will work forever. The truth is that their system will only work for a little while.

Managing ADHD successfully in the long-term isn’t about finding the one right way to manage your ADHD.

Managing ADHD is about riding the ongoing waves of constructing management tools, watching them fall apart without shame, and then constructing new management tools with excitement.

Together, we surf the long-term waves of constructing your management strategies, watching them disintegrate, and then we create new ones. So, for a little while, you go to the new gym near your house, but then you stop going. No shame. That’s part of ADHD. First, let’s cancel your membership right now, before you forget. Then we focus on what is exciting you and what will help you exercise now. You want to try hot yoga? Awesome, until it isn’t. We focus on the core and let the contents change. [If you jumped down to read this section because you were in the structure section, go back up now and resume at the Micro Structures subsection]

Can Therapy Help Manage ADHD for Me?

Section TL/DR: Yes. Click here to work with me.

If you’re thinking you’d like to work with me for treatment of ADHD, click here and fill out my contact form before you forget.

You can read the rest of the resources here after you fill out the contact form.

What Are Some Resources for Managing ADHD?

Best books on ADHD:

• “ADHD 2.0: New Science and Essential Strategies for Thriving With Distraction—From Childhood Through Adulthood” by Hallowell and Ratey
• “The ADHD Field Guide for Adults” by Osborn and Gude.
• “The Couple’s Guide to Thriving with ADHD” by Melissa Orlov and Nancy Kohlenberger
• “The ADHD Effect on Marriage: Understand and Rebuild Your Relationship in Six Steps” by Melissa Orlov.

Best social media focused on helping ADHD:

• YouTube: @HowtoADHD.
• Instagram:
  • @drbotyler.
  • @neurodivergent_insights.
  • @catieosaurus.

FAQ

Q: Does therapy work for ADHD in adults?

A: Yes. When I do therapy like this, my clients’ lives, work performance, and relationships improve significantly. And, sometimes, we have to keep doing therapy because you still have ADHD and can use an external check. In those cases, I often decrease the frequency of sessions and sometimes even reduce the length to 25 minutes (down from 50 minutes). This helps me help you engage in the recreation of your management methods when they fall apart.

Q: What type of therapy works for ADHD?

A: This type of therapy is Cognitive Behavioral Therapy, with a heavy emphasis on the behavioral part of CBT. CBT is an effective therapy for a wide range of clinical issues, including ADHD, and research suggests that it increases the benefits of medication alone.

Q: Is therapy or medication better for ADHD?

A: To quote one article[3], “CBT + medication outperformed CBT alone for ADHD symptoms, organizational skills, and self-esteem, although its superiority tended to decrease over follow-up.” The lay translation is that therapy (specifically CBT, as I provide) is more effective with medication. In this study, after therapy ended, the benefits of therapy faded. Which is exactly why I sometimes do ongoing therapy for clients with ADHD, as I described in the answer to my first question.

YOU DID IT! YOU READ THE WHOLE THING! YAY!!!!

[1] Modesto-Lowe, V., Farahmand, P., Chaplin, M., & Sarro, L. (2015). Does mindfulness meditation improve attention in attention deficit hyperactivity disorder? World Journal of Psychiatry, 22, 5(4), 397-403. doi: 10.5498/wjp.v5.i4.397

[2] Kim, H.-H., Jung, N.-H. (2025). Mindfulness-based interventions for adults with ADHD: A systematic review and meta-analysis. Medicine, 104(37), e 44308. doi: 10.1097/MD.000000000004430

[3] Cherkasova MV, French LR, Syer CA, Cousins L, Galina H, Ahmadi-Kashani Y, Hechtman L. Efficacy of Cognitive Behavioral Therapy With and Without Medication for Adults With ADHD: A Randomized Clinical Trial. J Atten Disord. 2020 Apr;24(6):889-903. doi: 10.1177/1087054716671197.

This page lists the awards, publications, media & news mentions for me, Eric FitzMedrud, Ph.D. 

I wrote an aWArd-winning Book!

My book, The Better Man: A Guide to Consent, Stronger Relationships, and Hotter Sex, is in print. I’m honored to say that the book won the following awards:

• Gold Medal: New York Big Book Award, Men’s Health
• Gold Medal: New York Big Book Award, Sexuality
• Silver Medal: Benjamin Franklin Independent Book Publisher’s Assn. Award, Psychology

• Silver Medal: Independent Publisher’s Book Awards, Sexuality/Relationships

• AND was a Finalist for the Foreword INDIES award in Family & Relationships.

Learn more about the book here.

Publications

(alpha by author)

FitzMedrud, E. (2023). The Better Man: A Guide to Consent, Stronger Relationships, and Hotter Sex. Los Angeles, CA: Wonderwell.

Wall, K., Nye, F., & FitzMedrud, E. (2013). Psychospiritual integrative practices. In G. Hartelius & H. Friedman (Eds.) The Handbook of Transpersonal Psychology. Malden, MA: Wiley-Blackwell.

Wall, K. Warner, A. & FitzMedrud, E. & Meritt, K.(2015) Self-compassion in psychotherapy: A psycho-spiritual integrative therapy approach. I n T. G. Plante (Ed.), The Psychology of Compassion and Cruelty: Understanding the Emotional, Spiritual, and Religious Influences. Santa Barbara, CA: Praeger.

Presentations

(most recent first)

FitzMedrud, E., & McCracken, M. (2024, April). Clinical Case Session: LGBTQI+ Clients with Problem Sexual Behavior. The Emerging Themes in Behavioral Health Conference, Los Angeles. In person.

FitzMedrud, E., & Randall, A (2017, June). Ethics and multiple relationships when therapists serve their sexual minority communities. Presented at the American Association of Sex Educators, Counselors, and Therapists Annual Conference, San Juan, Puerto Rico.

FitzMedrud, E. (2017, February). Polyamory agreements 101: For therapists. Presented at the SAAR International Academic Polyamory Conference, Berkeley, California.

FitzMedrud, E. (2017, February). Polyamory: A quick introduction. Presented at the SAAR International Academic Polyamory Conference, Berkeley, California.

FitzMedrud, E. (2016, March). Keeping your relationship strong while parenting. Presented at Parent’s Nursery School Parent Education Night, Palo Alto, CA.

FitzMedrud, E. (2016, February). Polyamory: A quick introduction. Presented at the SAAR International Academic Polyamory Conference, Berkeley, California.

FitzMedrud, E. (2016, February). Dealing with desire differences and deadlocks: A clinician’s guide. Presented for The Alternative Sexualities Health Research Alliance (TASHRA) training for Mental Health Care Professionals.

FitzMedrud, E. (2015, November). Sex, intimacy, and cancer. In Sharing Knowledge & Inspiring Hope. Presented at Bay Area Cancer Connections Annual Conference & Resource Fair.

FitzMedrud, E., Sauln, C. Langer, K., & Remigio, R. (2012, February). Spiritually oriented psychotherapy in community mental health settings. In Spirituality: Promises and pitfalls. Presented at the Association of Transpersonal Psychology/Institute of Transpersonal Psychology biannual conference.

FitzMedrud, E. (2013, October). A clinical model for sensitivity to spirituality. In Therapeutic Issues of Spiritually Transformative Experiences. Poster presented at American Center for Spiritually Transformative Experiences, 2^nd annual conference.

IN Media & News

FitzMedrud, E. (July 20, 2023). Opinion: What Masculinity Means. The Washington Post. [Links wouldn’t work unless you’re a subscriber]

FitzMedrud, E. (November, 11, 2023). I Help Couples Improve Their Sex Life. Here Are The 4 Things I Wish More Men Knew. HuffPost Personal.

Gale, A. (November 15, 2022). Dad Backed for Refusing to Pay for Polyamorous Stepson’s Partners on Trip. Newsweek. 

McKelvey, C. (March 4, 2017). Is Relationship Anarchy the Future of Polyamory? Vice.com.

Ross, M. (August 21, 2023). What Ken teaches men: Bay Area psychologist examines the emotional growth of Barbie’s boyfriend. Mercury News.

POdcasts

Blog

Before I go into this discussion, I want to identify that the anger that I’m referring to is not anger that comes with domestic violence, sometimes also called intimate partner violence. When there is violence, these principles and the ways to treat them are very different. If you aren’t sure if the anger in your relationship is being expressed through domestic violence, follow this link for help identifying domestic violence.

Types of Anger

I like to think about anger as coming from three potential triggers. The first is primary emotions. That is, the person feels sad, scared, vulnerable, or jealous. But rather than feeling and expressing that emotion directly, they respond to whatever is causing it with anger. That’s the secondary emotion. The second anger trigger is injustice. That is, the client experiences a violation of their physical or emotional integrity and feels anger, which gives them the energy and intensity to reassert their emotional integrity. A clear physical example of this is if someone hits their thumb with a hammer and they get angry and begin swearing. Their body doesn’t know that the hammer strike was accidental. Anger is an evolutionary adaptation intended to help the person generate the strength to fight off the bear that might have caused the injury. The third trigger is a sensory sensitivity. A good example of this is someone who experiences intense and immediate anger in response to nails on a chalkboard. Each of these types of anger problems requires slightly different treatments from the therapist.

Anger as a Secondary Emotion

Anger, as a secondary emotion, is the most common anger problem I see in my practice. I like to view this as the person’s best effort to soothe an uncomfortable primary emotion. For example, if sadness feels intolerable to me, I’ll feel more comfortable getting angry instead. My first intervention for anger as a secondary emotion is to try to help the person get to safety. Then we improve their ability to self-soothe. Self-soothing is a complex skill. I break self-soothing skills into six types: cognitive, emotional, social, mindfulness-based, sensory, physical, and distractions.

The next intervention that I will try is to help the client develop the capacity to tolerate the expression of the primary emotion. Eventually, instead of getting angry, the person might say, “I feel really hurt when you criticize me because pleasing you is really important to me because I love you.” Vulnerability like this can end threats and increase intimacy.

The third intervention, which in some cases is not necessary, is to help the client develop a deeper source of self-confidence. If small daily issues are creating intense vulnerabilities, it may be necessary for the client to cultivate a way of creating a sense of self that is based more in values and less in performance, or more in their intentions and behavior and less in other people’s responses to that behavior. This kind of work may be a little slower but pays deep dividends in a wide variety of situations beyond just helping to decrease anger.

Anger as Defense Against Injustice

The first intervention that I like to bring to clients who are using anger to defend against an injustice is to question whether they actually are experiencing an injustice. It is very common for clients to walk in the door with a lot of expectations about other people’s behavior or how loving partners must treat them in a relationship. Most of these are actually very idiosyncratic and boil down to a belief that, “When I love people, this is how I behave and the capacities that I have and I expect others to feel, think, and behave the same way under similar circumstances.” Furthermore, there are a variety of situations where one or more social pressures might help us to believe that we are experiencing an injustice, when really all that is happening is that we are having our expectations violated. This is common when people with some kind of social privilege do not get treated to the entitlements they expect with that privilege. A fairly common example of this in my practice is when men who work get angry at the state of the home when their wives are stay-at-home parents. Even very liberally minded-men bring a host of subtle beliefs about those experiences which can be challenged relatively easily by asking when the last time was that they watched their children for 40-60 (or in the Bay Area 80-100) hours a week alone. In addition to those techniques for challenging expectations, I can also bring tools from Cognitive Behavioral Therapy to bear to aid in exposing, questioning, and changing beliefs where appropriate.

Sometimes unfortunately, even in loving relationships, there is actually an injustice that has triggered the anger. One simple example, would be when one partner calls another a derogatory name. Anger might be an appropriate response here to establish a boundary on inappropriate argument behavior. But how long is that anger necessary to establish that boundary? Once the injustice has been brought to the partner’s attention, can the angry person let the anger dissipate or do they nurse the anger and keep it cycling and intensifying? When there are actually identifiable injustices I work with clients to help create decision-making processes so they can use the minimal amount of anger necessary to bring the injustice to halt and then help then with the self-soothing techniques alluded to above to help bring the episode of anger to an end.

Especially when injustice is present in a relationship, it is probable that the person coming to me for treatment for anger is not coming in for a single angry out-burst. More often, the injustice (or perceived injustice) is a repeated event. At some point, it is valuable to ask my client, “So, why are you choosing to stay with a person who treats you with injustice on a regular basis?” The question is sincere. Sometimes my clients have good reasons to stay with a partner who treats them with injustice. In those cases, I work with my client to acknowledge that whatever is behind that reason, their choice to stay with such a partner means that they have also chosen to receive the injustice as the price to pay for the benefits (however, please see the caveat above regarding violence which is a different situation than what I am referring to). Sometimes, by helping my client to see that they have chosen to receive that injustice and helping them articulate the reason(s) they have made that decision can help them to accept the injustice with equanimity instead of anger.

Finally, if I am seeing a client in individual therapy for an anger problem which is appearing in their relationship, I will recommend couples therapy. A couples therapist has a lot of different tools to help clients end cycles that lead to anger at injustices.

Anger Caused by Sensory Triggers

When clients report that certain noises set off their anger, the anger pattern often follows a characteristic pattern. First, it includes a rapid escalation. Second, the person remains agitated for extended periods of time following the initial stimulus. Third, because the process is so rapid, the client will report that they feel like they have little control over the process to prevent the anger from arising. Because there’s such an immediate escalation, of the three triggers, this one can be the hardest to work with.

One of the best ways to start, is to help the client identify and acknowledge the sensory trigger to their partner and loved ones. Sometimes, a supportive family or partner can do something to accommodate these sensitivities, or at least, to begin understanding, expecting, and preventing the client’s response. Sometimes, there’s also a power for change when others respond by identifying the sensitivity as in, “Honey, I think you’ve been triggered by that loud noise, do you want to go reset?” instead of yelling defensively as in, “Hey don’t yell at me, I had a rough day too!”

Eventually, these reminders and this awareness can help the client divert their angry response by removing themselves from the situation instead of expressing anger. The client can go to a different room, put in ear plugs, change the scents they are smelling, or something else to reset from an environmental trigger.

But the very best way to end this kind of anger sensitivity is to get treatment for it. Sometimes, this kind of sensitivity is caused by PTSD, ADHD, Autism Spectrum disorders, sensory processing disorder(s) unassociated with another disorder, or another medical or psychological cause.

Conclusion

One of the most important things to remember about a pattern of anger is that we all have weaknesses. We all have behavior that we may not be entirely proud of. What defines us as a person, what defines our character is not whether we have weaknesses, and not even which weaknesses we have, it is whether we are willing to acknowledge, accept, and do something about our weaknesses to minimize the ways that they hurt us and others.

Contact Me

It is common for people who haven’t been in couples therapy to wonder if it works or not. Given that the reason I love my job is the rewarding feeling I get when I help a couple improve their relationship, and that this happens regularly, I wanted to offer a few thoughts on that topic starting with an acknowledgement that it doesn’t always work.

No, relationship Therapy doesn’t work when . . .

In my initial phone call with prospective clients, I ask a few screening questions. Relative to couples therapy I ask whether there has ever been any domestic violence between the member of the relationship. When there is domestic violence as a part of the negative relationship patterns conducting therapy with safety and emotional honesty is not likely to be possible. While there are some situations where the partner violence is infrequent or minor enough for me to work with the couple, I often recommend that they seek individual therapy (which I could provide to one member) to help stop the pattern of violence before couples therapy.

I also ask about alcohol and drug use. When one or more people in a relationship are having a hard time regulating their use of substances, that person’s relationship with the substance, shame, and the emotional and cognitive consequences of being under the influence are likely to interfere with that person’s ability to participate in the relationship therapy effectively.

In addition to these issues, there are some much less frequent issues like individual crises related to safety or ongoing compulsive behaviors that may make couples therapy less effective for a time as well. It is my commitment, based on a principle of integrity, that when I consult with new potential clients I am honest with myself and with them about the limits or potential limits of the therapy. If I don’t think I have a good chance of helping, I won’t bring you in. I will share why not, and I will offer recommendations that might help you.

Yes, relationship therapy works when . . .

Most of the time I am able to help my couples counseling clients. There are some things that help the couples counseling to be more effective. Chief among these is a capacity for emotional self-regulation. That is, the ability to slow reactions, to be curious about your partner’s meaning, and to acknowledge when you are too upset to be productive. Don’t worry if you aren’t perfect at these skills, no one is. The therapy can help you develop them if you need some more support, but a certain minimum capacity with this can really help the therapy be more effective faster.

Another thing that really helps and which I ask about in the first session, is the reason that you love and respect each other. If you can answer this question with ease (and even better if doing so generates a sense of connection between you) then the therapy has a very good chance of being effective. This base of respect and mutual appreciation, helps become the springboard for experiences of empathy and kindness that can help replace the old patterns.

Finally, another facilitator for couples therapy is when both members of the couple are willing to make their own changes. I help couples to turn complaints about their partner’s behaviors into opportunities for the complaining partner to change. Once you are willing to make changes, I introduce the communication tools and skills to help you make the changes you want to make to become the partner you want to be.

Why relationship Therapy works

Whether clients bring those prerequisites to the therapy or we’re developing them during the therapy, from the first session I interrupt and stop negative communication patterns from taking place in my office. I do not sit back but lean in, ask questions, and make suggestions about those negative patterns.

Instead of those old patterns I introduce a host of new communication tools that I have written about in more detail in other blog posts. Soon enough, the skills are natural and comfortable for you that you’ll use them outside of my office and you will be to have conversations that would have turned into an argument with relative ease.

This technical skill is certainly important but there’s another element I want to point to. An effective therapist makes a big difference. Whether you call if called couples counseling, marriage therapy, or relationship therapy I focus on this kind of work. Due to that focus I can detect ineffective communications in body language, tone, and your partner’s reaction very quickly. That means I can intervene earlier.

If you are still left wondering if couples counseling can save your relationship, give me a call. In our 15-20 minute call, you can express you concerns. I promise to be honest with you about whether I think I might be able to help and why or why not.

Contact Me

Many men experience erectile disorder (ED). In my practice, I often see men who want to become better lovers. These men often come to treatment because something has gotten in the way of the erectile strength they previously enjoyed. Whether it is because of erectile disorder, premature ejaculation, delayed ejaculation, ageing, diabetes, or something else, the final straw that brings these men to break their silence and to ask for help often boils down to what their penis is or is not doing during sex.

What Men Think Makes Good Sex

The first thing I need to do is challenge some of their notions about what constitutes “good sex.” So I ask a few questions, “What makes for a good sexual experience for you? What makes for a good sexual experience for your partner? How do you both feel during good sex? How do you feel after good sex?”

As my male clients respond they often give me a list that starts with body parts and points directly to their perception of the problem, “a hard erection” they might say, or “my partner is well lubricated.” When I redirect them to the subjective experience of the sex that they are describing they eventually shift to the tones of the sexual experience using words like, “hot,” “intense,” or, “passionate.” Usually with just a little more encouragement they can talk about the subjective emotional experience, “powerful,” “desire,” “I feel s/he is open to me,” “connected,” or “merged.” Then I ask the last question to understand their experience or expectation of good sex, “how do you feel after good sex?” The answers are often very similar, “connected,” “close,” “peaceful,” “at ease,” “one.”

Challenging Expectations About Erections

In most cases, I am able to ask some question that challenge all their notions about good sex. Fortunately, I work in Silicon Valley and the vast majority of my clients are liberal and have broadly accepting views of sexual diversity. For those clients, I am able to ask if they think lesbians can have good sex. They invariably say, “Yes.” And then I ask, “but do you think lesbian women can have really good sex?” and again they respond “yes.” So I finish with, “how do you think they do that without an erection?”

The answer of course is that lesbian sex creates good sex by using methods other than a penis. From their frame of reference their sexual pleasure and their capacity to give pleasure has often revolved around their erections. While many of them have considered oral sex or manual sex as receiver or giver, they have often equated really good sex with the functioning of their penis.

From here, I admit that I’m not always able to help men improve their erections the way they would want. For example, sometimes medical conditions or medications prevent improvement. But before we try to find which of the many ways that talk therapy can help improve sexual function, having had this brief conversation, they usually now imagine a future where they can have good sex and can give their partner the experience of good sex even if they don’t experience the erections they would like.

Direct ED Treatment

Once this groundwork is laid, I will bring the practical tools for better erections like sleep, exercise, diet, cutting out alcohol, pelvic floor exercises, emotional vulnerability and connection, elimination of goal orientation (for more details see the description of the Sensate Focus Exercise here), and a referral for a medical examination to help the client. One of the beautiful things about having had the conversation I described above about good sex is that now that the man knows that good sex isn’t dependent upon a strong erection (even though it might be his preference), there’s suddenly a lot less pressure and stress about doing this practical work. And less pressure and less stress are good for erections.

I also have to admit that until very recently, I had fallen into the same pattern, so I really understand what it is like. Though a psychotherapy practice is not a tech start-up, I found that grad school, licensing exams, work at other jobs while building my practice, and supporting my family while living in this area with its high cost of living, required me to work for years at or above the 60-hour per week mark.

So, as a therapist, husband, and father of three, I have had to find some solutions to the relationship challenges posed by Silicon Valley work schedules. This post lists five solutions to the work-life balance challenge in Silicon Valley: Values Clarification, Practical Decision Making About Happiness, Massed Time Together, Reallocation of Financial Gains, and Relationship Rituals.

Values Clarification

Sometimes, the client wants to change their work-life balance, but they aren’t sure how to identify which changes to make. One way of trying to resolve a work-life balance problem is to call to mind the values that you have. Do you value money, success, and accolades or family, connections, and your relationship more? Many of my clients will answer a question like this by saying, “Both!” The question, though, is intended to help with the process of allocating the temporal resources first to those things that matter the most. I have seen it time and again in my therapy office where a short-term effort to support and improve career, like grad school, a big project, or vying for the next promotion, becomes a never-ending sacrifice of family time and energy for the next career move that will finally, “Get us to where we need to be.” The work efforts continue because the people in the relationship don’t ever reallocate their time and energy. Maintaining the career trajectory or the current salary becomes a never-ending task. Clarifying your values can help you bring your behavior in line with your goals. Questions like, “What do you want people to say about you at your funeral?” can help with this process. Then, you just work backwards from there by asking questions like, “What do I need to do with my time and energy today in order to contribute to those words at my funeral?”

Practical Decision Making About Happiness

Another way to consider this question is to acknowledge that at least one reason to continue to pursue career achievement is based on the idea that, “If I get just a little bit more money, I’ll be able to stop chasing it anymore.” Yet, research consistently shows that there is a threshold above which more money won’t make you any happier. In one analysis, that number for California is $92,000 per year (read the original research here). Even if we allow that dollar figure to be fudged a little bit higher for the higher cost of living in Silicon Valley, ask yourself if you are already at that level. If so, yet you still feel unhappy, you may need to ask whether or not the source of that unhappiness is internal. That is, do you feel unhappy with your life because it is hard for you to appreciate what you have and to be content with it? Are you negatively comparing yourself or your life to others? If you have answered yes to these questions, you might want to refocus your happiness improvement efforts inward instead of outward. By tipping your work-life balance toward more life, you may find that you are better able to enjoy your family, relationships, and the beauty of nature. This may help you feel happier and more content, even if it means that you have less money.

Massed Time Together

If none of the above considerations moved you to consider a change and you are still determined to work 60+ hour work weeks, then you would be in good company with the majority of my clients and with me for many years in the past. Work can be very rewarding. Yet, no matter how rewarding, that 60+ hour work week will take a toll on your relationship unless you do something to counterbalance it.

One suggestion that several couples that I have worked with have found helpful is to plan for punctuated breaks in the crazy schedule. Product launch coming up? Great, plan for a week off afterward. Use some of the wealth you have earned to go on a beautiful vacation that emphasizes the kinds of activities that the two of you did when you fell in love.

Reallocation of Financial Gains

Especially if you didn’t grow up with the kind of wealth that is now available to you in Silicon Valley, you may need to learn a different way to distribute your financial resources. For example, you may find that you are having a hard time finding the time to spend with each other because between the work schedule, caring for the kids, and household maintenance, there isn’t a lot of time left over to spend with each other.

This process can be intensified if you grew up poor. You may have gained a “do-it-yourself” attitude that helped to conserve money at times when it was scarce. So now you save and work almost as hard at home as you do at work. However, if you do things like hire a nanny to help with child care, hire someone to assist with housecleaning, etc., you may find that you are better able to maximize the quality of the time that you have at home with your partner.

There is a caveat to this solution. As you spend more of your financial resources trying to free up time for your relationship, you may find that it creates additional pressure to maintain your income and career trajectory.

Relationship Rituals

Okay, so you work a 60+ hour work week. If you can identify a sacrosanct time for you and your partner, that nothing can violate. Not the product launch, not the deadline for China, and not the International Flight, then you will be showing your partner that s/he is a priority for you all the time. That may sound impossible at first, but it need not be. There are just 3 steps to making this work.

First, you identify the day and the time in the week that your regular time to foster your relationship with your partner will be. I recommend at least 2 contiguous hours without interruption.

Second, if something does come up that you have no control over and that really is a non-optional career requirement, like the product launch, the deadline for China, or the International Flight, you don’t just skip that time. Instead, you move the time preferably to before the interfering event, not after it. This way, you are showing your partner that nothing can take away the time you have for them.

Third, you keep to it. You need to tell your boss and/or your team about this time so they know when you are simply unavailable. They need to understand that keeping this time sacred and that your job satisfaction is related to their support of that time. Hopefully, you don’t put that relationship time at 5 pm on Tuesday if that is the optimal time for the teleconference with China. If travel is a consistent work requirement, you have to make it a point to be home for a few hours before a departure.

Conclusion

People in Silicon Valley are often talking about changing the world and making “life-hacks”. But the easiest and most definitive way to change the world is to start with yourself. The changes to create work-life balance aren’t always easy. After I propose these changes, I may hear about corporate culture or requirements for advancement. I sometimes hear the argument that my client fears not reaching their optimal career achievement. But I rarely hear people talking about their complicity in perpetuating those corporate cultures, or optimal relationship development, or even optimal happiness. Much of my work is about helping people find meaning in their lives after having sacrificed that meaning for money and success, or helping them put their relationships back together after years of neglect. “Most fast and break things” is indeed an apt motto for the area, but from my side of the therapy room, when “things” become “people” and “relationships,” it is less laudable than lamentable.

I want to end on a personal note. I mentioned that I have reduced my working hours after years of working above 60 hours per week. Now I’m at less than 50 per week. The day that I announced to my kids that the schedule was ending and I would be home more, they literally jumped up and down, cheering, and then held a celebratory procession through our home. The corresponding reduction in income never crossed their minds (though they are old enough to understand the correlation). That moment of celebration confirmed for me that I was more valuable to them than what I could earn to give them. I encourage you to believe that you are more valuable to your partner and/or children than what you can earn.

First, a reminder. I don’t write about any specific clients in my blog. The examples below are composites from multiple clients. I am presenting common issues that I have seen among many clients.

Anxiety

The myth high-achieving people have about anxiety is that they shouldn’t have it or that it should be under control. The reality is that their anxiety has served them, and their career may even be encouraging anxiety. In therapy, we can find other, more sustainable ways to fuel a positive feedback loop for success while reducing the ancillary suffering that is caused if anxiety is the fuel.

Many people with the drive to be high achievers build an expectation for themselves of ever-rising success. In fact, some of them have never experienced a significant failure. They have found themselves propelled into situations of increasing responsibility, not just for themselves and their own success, but the success of their team, their product, and then their shareholders, investors, or a whole company. When you have had a rocket-like career trajector,y the fast pace, the demands, the staggeringly fast changes from concept to product launch, from start-up to IPO, or from untouchable golden-child to a career crash and burn can be shocking, disorienting, and can rock the foundations of identity.

The clients who come to me for therapy for anxiety issues have often experienced multiple changes, identity or role confusion in their companies, demands for work pace or perfection that aren’t sustainable, and more. One thing that often happens is that because the person’s abilities really are phenomenal, when faced with what would for most people be an impossible task, the high-achiever doesn’t admit that possibility. She or he just identifies what it will take to make it happen. The ensuing lack of sleep, loss of relationship, loss of perspective, coupled with the accolades of a shower of money for success, high compliments, and further expectations for even more results in the future, can all become fuel for anxiety.

Eventually, the highly successful person may begin to experience anxiety for a number of reasons.

• Simply experienced so much stress for so long that they don’t find it easy to calm down.
• Fear that they have been a fake all along, and the next task will be the one that reveals that they really aren’t as smart or skilled as the world-class peers next to them.
• Attached so much identity to their habit of success that the risk of failure threatens the core of their understanding of who they are.
• They may have become successful because, like many successful and intelligent people, they have beneficial obsessive or compulsive tendencies. But those tendencies have recently begun to spin out of control.

This is far from an exhaustive list, but it reveals that there are a lot of possible ways that a high-demand career and a high-achieving personality can ignite a positive feedback loop of anxiety and success.

Relationship Challenges

The myth high-achieving people have about their relationships is that if they are high-achieving in one domain of their life (i.e., career), they will be high-achieving in other domains as well (e.g., relationships). The reality, though, is that high achievement in any domain takes practice and expertise, and relationship therapy can provide the tools and practice to become more expert in the domain of relationships.

One characteristic of high career achievement and advancement is a single-minded willingness to pursue a goal. Anyone who has completed graduate school knows that it is important at certain times to sacrifice body, sleep, healthy food, healthy exercise, and even relationships with a partner or kids to surmount the next hurdle. Now take that same pace of demand, concentrate it, attach to it the promise of huge amounts of money, and put that cycle on perpetual repeat. . .that is work in Silicon Valley. No wonder so many companies call their sites a campus.

I want to identify two ways that I have seen this work pattern interfere with relationships. First, from an attachment perspective, the amount of time spent together is essential for a high-quality attachment. In my experience, when a client works more than 60 hours per week, there is little chance that they have much energy left afterward to give to their relationships. Most of the time, when they come home, they simply try to refresh their energy and attention stores. Maybe they have a little left over for kids, but for partner and sex, the likelihood is small. Yet, beyond that, I have worked with clients who work 80 or even 100 or more hours a week for some periods of time. What I have seen is that the more hours a person works over 60, the more and more hyper-focused they become. If at 60 hours per week the high-achiever has less to give to their partner, it becomes increasingly likely that by 80 hours of work per week they are actually demanding more from their partner. Unable to sympathize, they fixate on the mission to complete the next work hurdle. Much more work than that, and the person on my couch feels to me like a walking zombie. They have a very difficult time connecting to me as a person; even talking and following a conversation thread with them becomes a challenge.

Another aspect of this ability to sacrifice single-mindedly for a purpose is asynchronous personal development. That is, the person in the relationship may be a world-class expert in software whiz-gigs or business howsie-dos, but the expertise to develop a long-term relationship remains in its early stages. In the meantime, the partner, especially if they are not working in the tech industry, may be developing relationship expertise all the time by relating to friends and community members and filling up with relationships to compensate for the time alone that the high-achieving partner’s work demands take.

Sometimes, this high achievement is also paired with personality traits that can make relationships harder, too, like those that emphasize precision and deemphasize empathy or interpersonal warmth. In some cases, this might simply be alexithymia (a lack of awareness of and words for emotions), which is easily remedied in therapy with some mindfulness skills, somatic focusing exercises, and emotional vocabulary building. Other times, the personality traits are much deeper, and the person has difficulties forming deeper relationships with friends, work colleagues, and long-term relationship partners, too.

A First Setback

The myth high-achieving people have about failures is that high-achieving people don’t fail. Most know that this is false intellectually, but dealing with the emotional reality of a big setback for the first time can be hard, and therapy can help.

Sometimes clients come to see me after a first failure. It might be being fired from a job, a poor performance evaluation, or the closure of a start-up. I have seen time and again that when a client has put a lot of stock in their personal identity in their perpetual and unmitigated success, a first failure can be a real blow. Very literally, such an event changes their perception of their place in the world and history. To some, that might sound a bit grandiose, but the reality is that people in this area are world-changers. When you think you are in line with your company or your ideas to be a part of an industry or world-changing event, and the journey suddenly takes a left turn, then the story you are telling needs to be updated.

Was the challenge caused by being too trusting in a cutthroat world? Was the challenge that you weren’t collaborative enough? Maybe even worse was what went wrong, simply not in your control, revealing to you that your perception of yourself as invulnerable wasn’t as accurate as you hoped? When I work with clients around issues like a first failure, I try to help them focus on what they can learn from the experience, identifying what is and is not in their control, and on what they want to change that is in their control. Most of my high-achieving clients really like this part of the work because it plays right into their usual high-achieving mind-frame. Find the problem and fix it.

However, there is also another thread that I try to introduce into the therapy. I try to ask questions about what they want to build with their life, who they really want to be, and what their values really are. These questions often shift the conversations in therapy away from “What happened and how do I fix it?” to “What do I really want from here?” This second set of questions is also important because it allows a reorientation in life priorities and source of identity so that career setbacks won’t have the potential to cause instability in the future.

Therapy for Development

The myth high-achieving people have about their relationships is that if they are successful, they don’t need therapy because nothing is wrong. But therapy isn’t only about what is wrong; sometimes it can focus on what can be better.

Sometimes, clients come to therapy not because there is something wrong, but because something can be better. High-performing clients are sometimes looking for a person to help them in relationships, career, or self-regulation in a way that requires a therapeutic lens. For example, even when a relationship is good, it can sometimes be beneficial to have a therapist help you figure out how to deepen the emotional bond, or a client planning a pitch to a VC firm might want to exude comfort, not just remove anxiety. Sometimes, the right person for those developments might be a professional coach. Other times, the challenge comes from a psychological source with deep roots, and it helps to have a therapist who can help you embrace the present by more fully letting go of the past.

Conclusion

I have spent most of this post identifying the common challenges that high-achieving clients bring into therapy. I hope that this post exposed the myths about both high-achieving people and therapy. High-achieving people face unique stressors. The illusion that high achievers don’t need help is false. I often ask my clients who are comparing themselves to other high-achievers if they know anyone else in therapy, and they say “no”. Then I ask them how many of their friends they have told that they are in therapy, and they say, “None”. This shows that high achievers are often comparing their insides with other people’s outsides, which is an unfair comparison. Finally, therapy isn’t only for people with mental illness. Though it can also help people with more serious issues, therapy can also help clients who are facing new challenges, who need help with managing the unique stress of rapid career advancement, or who experience some relationship challenges because they have focused so much on developing business skills that they need to balance their life skills.

Contact me and we’ll have a conversation to make sure your needs and my services are a good fit.